Hospitalization, even with all available medical technology, remains a trying experience. The same concerns, apprehensions, and fears exist today as they did centuries ago in the face of dangers to well-being and sometimes to life itself. The psychological well-being of hospitalized patients is, therefore, not only for humane considerations but also for reasons connected to health and recovery: patients may do better when undergoing procedures, recovering from operations, or surmounting the side effects of treatments if they are relaxed, rested, and feeling hopeful.

Hypnosis is a process by which an individual is guided from his or her usual state of consciousness to a condition that is marked by psychological and physical relaxation; altered perceptions such as the slowing down of time or a change in one's body image; and a shift from analytic to synesthetic thinking, that is, the mind shows less dependence on logic and a greater receptivity to sensations and feelings. The resulting change in perception and thinking is known as a trance. The nature of the trance state varies from one individual to another.

The ability of hypnosis to induce deep multilevel relaxation, to quell anticipatory anxiety, to increase tolerance to adverse stimuli, and to intensify affirmative imagery can be adapted to the hospital setting for maximizing the mind's contribution to healing.

Hypnosis has recently seen a resurgence in its medical applications, with increasing sophistication in the ways it has been used for many clinical problems, in and out of the hospital.(1) Equally important, modern hypnotists, in contrast to earlier ones who tended to be authoritarian in their approach, encourage patients to determine the nature of their own experiences, that is, to develop their unique potential in their trance. They are also mindful of psychodynamic considerations. Thus, they use permissive and often frankly meditative methods and function as a guide to point the way to conditions of consciousness that are conducive to psychological adjustment and growth.(2)

Procedures performed under local anesthesia with or without sedation are often anticipated by the patient with the same apprehension as those requiring general anesthesia. The idea of being conscious during a procedure may be reassuring in one respect and unsettling in another. On one hand, the patient's sense of control is maintained; on the other hand, the patient may feel uncertain as to how he or she will deal with the experience. Even a simple procedure, like a spinal tap, can be approached with dramatic imagery: the mental picture of a needle may be much larger than the actual size of the needle. Similar distortions may also occur with regard to other procedures, such as cardiac catheterization, bone marrow biopsy, or sigmoidoscopy.

The anticipatory anxiety generated by the patient's fantasies about a procedure should not be neglected. It can turn a routine stay in the hospital into a nightmarish experience and negatively sensitize the patient to future hospitalizations.

The following case history illustrates some of the principles of hypnosis when used in the hospital with certain medical procedures:

The hypnotic phenomenon that perhaps inspires the most awe involves the patient who undergoes major surgery without chemical anesthesia.(3) According to Moll,(4) the first surgical operations on "magnetized" subjects were those performed by Recamier in 1821. (At that time, hypnotic phenomena were thought to be produced by the influence of magnetized objects.) Jules Cloquet followed him in 1829, Dr. John Elliotson in England, Dr. Albert Wheeler in the United States, and the well-known Dr. James Esdaile in India in 1840.

It is postulated that in certain individuals through hypnotic mechanisms, a sufficient level of endogenous agents--that is, those agents that occur naturally in the body--may be produced to block all perceptions of pain.(5) However, many author(6)(13) point out that pain is a sensation intimately intertwined with fear and that surgical procedures performed with hypnotic anesthesia may owe their success to the modulation of anxiety as much as to the neutralization of pain. Since 1950, interest in hypnoanesthesia has rekindled. Suppressed by the discovery of chloroform, ether, and nitrous oxide for more than a century, this renewed interest has been fueled not only by the growing sophistication in understanding hypnosis, but by new philosophies of patient care, such as the belief that patients should have access to any treatment modality capable of easing the stress of illness and its treatment.

It is estimated by some investigators(7) that 10 percent of the population could undergo major procedures with hypnoanesthesia. Others(8) estimate the figure to he far lower. Patient selection appears to be very important. Adequate studies are lacking, but good candidates for hypnoanesthesia are likely to be highly hypnotizable and especially adept at altering the processing of painful stimuli. While probably only a small percentage of patients can negotiate major surgery using the hypnotic trance as the sole anesthetic, a far more important percentage can benefit from the "softer" or more subtle therapeutic influence of hypnosis, as it is applied in an integrated fashion through the continuum of the hospitalization sequence. As such, hypnotic intervention can begin in the preoperative period, can be continued during the operation itself, and can be maintained through the postoperative stage to assist the patient through all phases of psychological and physical adjustment.

As is the case with hypnosis preceding medical procedures, preoperative hypnotic preparations center on exploring the patient's fantasies about the operation, neutralizing the mental set of anxious anticipation, and correcting the nefarious effects of destructive imagined scenarios. The patient is introduced to the idea of deep relaxation, taken through the steps of experiencing the hypnotic trance, and presented with affirmative images and statements relating to the sequence of events likely to be encountered in the operative procedure. If the medical hypnotherapist intends to be present during the operation, this fact is mentioned before surgery so that hypnotic contact may be more easily reestablished while the patient is anesthetized.

It has been assumed for decades that a patient in the deeper or even moderate levels of chemical anesthesia was in a state of other-worldliness and had shed all semblance of consciousness. However, some clinicians and researchers have reported patients who have remembered events that occurred during surgery when they were presumed to be unconscious. Crile(9) reported the case of a patient receiving nitrous oxide (as well as his own case in his autobiography) where some awareness of the environment was preserved. While nay-sayers have attributed these reports to insufficient levels of anesthesia, reports of more occurrences of partial awareness in documented deep anesthesia prompted studies to investigate this phenomenon.

In one study, Wilson and Turner questioned 150 postcesarean patients.(10) They found three patients who accurately recalled actual events and 46 who retained some dreamlike remembrances of the operation. More recent studies have focused on the hypnotic recollection of the operative experience, that is, asking the hypnotized patient to recall an operation. Consciously, some patients may have little or no recall, but others--especially those who are highly hypnotizable--are able, in the context of trance, to reexperience important events within the operative procedure. It has been reasonably well established that such patients are attuned, in such situations, to meaningful communications by the personnel who are present in the operating room, especially surgeons and anesthesiologists. It is therefore possible that surgical patients may be aware of negative comments on their progress by surgical personnel, to which patients may react.(11) If, for example, a surgeon says, "There's a lot of blood loss here," the patient may respond with a rise in blood pressure and increased heart and respiratory rate, making cardiovascular instability more likely, Hypnotherapists, in anticipation of this phenomenon, may add preoperative suggestions such as, "You will remain calm, deeply relaxed, peaceful, totally undisturbed by any conversation around you. Your mind centers on feelings of well-being throughout the operation."

As far as the hypnotherapist is concerned, the clinical implication of the retention of some awareness during anesthesia is that some degree of hypnotic contact and rapport may be established--or reestablished, if the groundwork has previously been done--during the course of the operation, for purposes of assisting the patient adjust to its vicissitudes. It is well known, for example, that if the patient's abdominal muscles are tight, the surgeon may order more anesthesia. This may not be necessary if the hypnotherapist gently whispers suggestions to the deeply anesthetized patient to relax his or her muscles.

Postoperatively, the patient who has already experienced the trance state can easily be given suggestions for dealing with all aspects of the recovery process, including rest, comfort, and return to harmonious biological rhythms (that is, normal appetite and sleep).

People who have suffered catastrophic illnesses or accidents usually have a long journey to recovery, and may require global adjustments in life goals, family dynamics, and self-image. Stroke victims, amputees, and individuals with spinal cord injuries, for example, need multi-level support to help them cope with their shattered world. Rehabilitation. therefore, is both a physical and a psychosocial process, aimed at assisting destabilized patients to regain optimal physical competency and psychological integrity. In the face of cataclysmic loss (of bodily function--as in hemiparesis (paralysis of one side of the body), aphasia (impairment or loss of speech), or quadriplegia (paralysis of both arms and legs)--the patient often questions his or her will to live. Other traumatic though less debilitating injuries, such as the loss of a finger, can engender severe depression, withdrawal from others, self-destructive thoughts, and a loss of self-esteem. It is clear that adaptations to such tragedies may have as much to do with their symbolic representations as with their objective realities.

The heartening advances of rehabilitation medicine are tied not only to technology but also to an appreciation of the complex psychological needs of patients. Staff members know how important their self-generated enthusiasm is in mobilizing their patients' optimism and how loss of motivation can stunt progress or foster regression. The following case history illustrates the application of hypnosis to the difficult process of rehabilitation.

For hospitalized patients with catastrophic illnesses, hypnotic treatment does not stop after the first consultation. A series of treatments over time is generally effective, as in the above example, since the goals are approached in small steps over the course of weeks or months. In such cases, it is advantageous to teach patients the skill of self-hypnosis so that they will he able to surmount periods of private distress, regain autonomy, and participate in their own recovery.

Cancer affects a person on many levels, from the cellular to the psychological. While the baffling varieties of its manifestations continue to he elucidated, there is an evolving awareness of its complex psychological dimensions. Cancer patients are likely to experience intense distress and pain--pain from the disease itself, from its treatments, and from the deep psychological and social changes the disease and its treatments induce.

Recently there has been a growing appreciation of the needs of cancer patients for support, open communication, understanding, and for the sensitivity and professionalism with which life-threatening illnesses need to be approached.

Hypnosis is used at several levels of cancer care.(5)(6)(12-14) First, it is useful as a means of dealing with the symptoms of the disease itself: pain and symptoms associated with specific or organ systems; and nonspecific symptoms such as fatigue, malaise, irritability, and insomnia. Second, hypnosis may be helpful in the management of the side effects of cancer treatments. This is very important because the side effects of chemotherapy and radiation--such as nausea and vomiting--are often so unpalatable that they may cause the patient to drop out of therapy. Third, cancer patients are faced with major psychological adjustments. Many view their diagnosis with nihilism and are forced to grapple with profound existential issues. Lastly, and still somewhat controversially, hypnosis has been aimed at modifying the course of the disease process itself through the medium of mental images.(15)(16)

The individual in deep hypnotic trance may experience any one of a variety of shifts in body image. The perception of oneself in space including, if appropriate, the presence of pain, can then be modulated by the influence of hypnosis on cognitive processes and self-perception. "I"--the core of the experiencing self--can be asked, in hypnosis, to modify its relationship to the feeling of pain. When contemplated, pain may take on qualities that were not immediately appreciated. It may he perceived as sharp, diffuse, warm or cold, as having volume, shape, color, and even sound.

Painful stimuli are recognized consciously and then elaborated into complex variegated sensations.(17) The mind can alter or neutralize the perception of painful stimuli. The wounded soldier continuing to engage in battle is one example of the mind's influence on pain and, by extension, all perception.

In a hypnotic trance, the field of consciousness has the potential of having more direct access to pain, to its associative networks in the central nervous system, and to the mechanisms underlying its processing. Thus, "hot" pain may be made to feel cool; pain that is perceived to be large and looming may be made smaller in volume; pain that seems oppressively close can be made to seem farther away; and, under certain conditions, pain can be abolished altogether.

In altering or removing pain, care must be taken not to block its warning function. In the early stages of an illness, a new sensation of pain or discomfort may be an important indicator for revising the therapeutic strategy. In more advanced cases, this is not as relevant. The following case history demonstrates some principles of hypnotic alleviation of symptoms due to cancer.

In the last few years, we have witnessed an interest in exploring the uses of mental techniques not only to guide cancer patients to a better frame of mind, but also to influence the disease process itself.(15)(18) Techniques span a wide array of approaches, most of which confine themselves to visualization in the context of hypnosis and/or meditation. Reports of positive results using these techniques are largely anecdotal. In spite of mounting evidence of links between the mind and the neurohumoral, immunological, and autonomic nervous system mechanisms,(18-24) the efficacy of mental techniques such as imagery, with or without the use of hypnosis, has not been demonstrated scientifically to affect the course of cancer. There is a need for more systematized investigations of these methods.

In the evolving philosophy of patient care, not only traditional and state-of-the-art therapies, but all modalities capable of enhancing comfort and well-being are approached with a willingness for evaluation, with a special awareness given to the importance of psychological factors in the healing, convalescent, and rehabilitative processes.

Today, hospitalized patients, faced with an alien environment, time constraints, and a panoply of novel procedures, are apt to need therapeutic approaches that attend to their psychological needs and to the human dimensions of their experience.

Medical hypnosis, a clinical science has undergone extensive conceptual evolution and technical sophistication in recent years, is increasingly understood as a treatment modality with the capacity to be applied, in selected situations, to a wide range of problems encountered in the hospital milieu.(25)

Of the phenomena potentially manifested during trance, multi-level (psychophysiological) relaxation, the modulation of painful sensations, the alleviation of drug side effects and nonspecific symptoms such as malaise and insomnia, the reduction of anticipatory anxiety, and the strengthening of motivation for recovery find the most usefulness. Lastly, and still somewhat controversially, is the application of hypnotic imaginal techniques in an attempt to influence the neurohumoral and immunological components of healing. As the healing process becomes more acutely appreciated as a multidimensional, dynamic phenomenon, and as therapeutic trance states become more accepted as valuable gateways to the enhanced communication between mind and body, medical hypnosis will increasingly solidify its role as an agent capable of assisting the individual toward achieving global health and well-being.

Gérard V. Sunnen, M.D., is Associate Clinical Professor of Psychiatry at the New York University Bellevue Hospital Medical Center. He is in private practice of psychiatry and clinical hypnosis in New York City.

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